Incorporating community into our model of well-being and illness

Thirty-five years ago, we discovered that well-being and illness are not the two ends of a single continuum. This insight came from the 1946 Preamble to the Constitution of the World Health Organization, which states: “Health is a complete state of physical, mental, and social wellbeing, and not merely the absence of disease" (emphasis mine). Thus, the two dimensions, “well-being” and “illness,” became our framework for guiding work on recovery.

Stated in simple terms, to achieve recovery, it is essential to make progress on the illness dimension through traditional biopsychosocial interventions. It also is essential to make progress on the well-being dimension through, self-help, self-directed care, social support, and peer support. Both types of care are required.

This two-dimensional array also is the basis of modern population health management. A moment’s reflection will assure you that use of these two dimensions generates four population subgroups, each with different well-being and illness needs. It is only in the past three to five years that we have begun to capitalize on this insight to guide population health management.

But we now realize that this model is incomplete. To move forward, we need to add a third dimension: community, which unfortunately was neglected in our earlier work. During the past decade, we have learned that the healthcare system only accounts for 10% to 20% of our health status. Fully 80% to 90% of our health status is due to what happens to us in our communities.

A few examples can be used to reinforce this point. One’s ZIP code is very predictive of how long one will live. Our communities determine what social and physical health determinants impinge upon us. They also determine what traumas we will experience at what stage of our lives. Thus, communities have great impact upon our well-being, our illnesses, and, ultimately, our happiness as well.

When we include community as the third element of our model, this dimension can range from very salutary effects on well-being at one end to very detrimental effects on the other. The clear implication for us in behavioral health is that we need to begin to engage in community interventions to promote these positive effects and mitigate the negative ones.

Initial steps are being taken to bring these public health strategies into behavioral healthcare and to bring behavioral health strategies into public health. This past fall the American Public Health Association hosted a symposium on this topic at the Carter Center in Atlanta. A summary of this effort will be available shortly.

In future commentaries, I will explore further the ways that the community dimension impacts upon our well-being and our illness.

It is amazing that we neglected this critical dimension for so long.